December 19, 2024 • 56 mins
Dr. Catriona Steele, president of the Dysphagia Research Society, discusses her journey in dysphagia research, including motivation from her pre-PhD days, and focuses on systematic reviews. She highlights the need for rigorous and transparent methodologies in evaluating research quality, introduces the FRONTIERS framework, and underscores the importance of continual learning and questioning in the field.
Episode Resources from Dr. Steele:
PRISMA guideline: Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Group, P. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Annals of Internal Medicine, 151(4), 264-269, W264. https://doi.org/10.7326/0003-4819-151-4-200908180-00135
Prospero: https://www.crd.york.ac.uk/PROSPERO/
Open Science Framework: https://osf.io/
Cochrane Collaboration: https://www.cochrane.org/
EQUATOR Network: https://www.equator-network.org
Covidence: https://www.covidence.org/
Rayyan: https://www.rayyan.ai/
Clinical Trials dot gov: https://clinicaltrials.gov
Frontiers Framework: https://www.frontiersframework.com
Episode Sponsorship:
The TIMS Medical team is excited to announce that ASPEKT-C will be included in upcoming releases of TIMS MVP in 2025, following close collaboration with The Swallowing Rehabilitation Research Laboratory.
The team at TIMS (www.tims.com) is honored to support the implementation of ASPEKT-C which assists clinicians in identifying the underlying mechanisms of impaired swallowing safety and efficiency. Additionally, the ASPEKT-C Method also enables clinicians to compare swallowing parameters to reference values in healthy individuals, offering valuable insights for improved care.
To learn more about ASPEKT-C, visit The Swallowing Rehabilitation Research Lab website. For updates on upcoming TIMS MVP releases, follow TIMS Medical on social media or sign up for email notifications at www.tims.com.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Today's episode of Swallow the Gap is sponsored by
Tim's Medical.
The Tim's Medical team isexcited to announce that Aspect
C will be included in upcomingreleases of Tim's MVP in 2025,
following close collaborationwith the Swallowing
Rehabilitation ResearchLaboratory, which was actually
founded by today's guest.
Hey everybody, Today I have DrKatrina Steele from the Kite
(00:21):
Research Institute and thecurrent president of the
Dysphagia Research Society.
Welcome, Thank you for joiningme.
Speaker 2 (00:27):
Thank you, tim, it's a pleasure.
Speaker 1 (00:28):
Yeah, absolutely.
Is there anything, before weget into this topic of interest,
that you wanted to tell peopleabout yourselves right now?
Speaker 2 (00:38):
Sure, well, I can start with just a little bit of
background.
So I trained as a speechpathologist in the early
nineties and worked clinicallyfor about 10 years.
I don't think I knew we diddysphagia before I went to do my
degree.
I thought I would be an aphasiaclinician and then my final
(01:02):
clinical placement was indysphagia and I fell in love
with it.
And then my first clinicalposition was in a home for the
aged, where the most commonreason for referral was
dysphagia.
And I've ever since, and aboutafter seven or eight years of
(01:23):
clinical practice, I wasfrustrated, mainly because I
loved all of the work we woulddo about diagnosis and I loved
fluoroscopy and we would put somuch effort into it.
And I felt that after all ofthat, we had one generic
intervention we were offering,which was pureed foods and
(01:46):
thickened liquids, and I wasfrustrated by that and inspired
by people at the time, likeMaggie Lee Huckabee, who were
doing rehabilitative work, andso that was really what drove me
back to do my PhD me back to domy PhD and I was fortunate to
(02:13):
get a grant just at the end ofmy PhD, and I've been now doing
this research for 20 years andlove doing it, yeah, and you put
out some very helpful stuff.
Speaker 1 (02:21):
I don't know how many times and I should probably
update what I'm referencing howmany times I referenced mole
thinner and steel.
As far as the variability ofswallowing, you know, highway
movement, of timing measures andthose types of things.
I think that's fantasticbecause it is my opinion that we
over-diagnose dysphagia and weover-restrict, and so I think
(02:42):
that's really helpful to havethat anchoring point to be like
well, you know, actually it'sokay that it initiated in the
pure form sinuses, because ifyou, you know, frame by frame
and time it, there was no, youknow, there are no adverse
outcomes and that's within atypical range that that sort of
thing too.
Speaker 2 (02:57):
So I think, yeah, I appreciate it.
So the you know, this theme ofwhat's normal or what is typical
has really become a focus ofour work over the last decade,
starting with Sonia'sdissertation really, and we're,
as you may know, we're trying tocharacterize reference values
(03:18):
across the IDSEE levels up toextremely thick, primarily in
healthy people on videofluoroscopy.
It's a big job and then also tolook in patient populations and
one of the big questions therewill be are there characteristic
profiles or people use the wordphenotype?
(03:38):
I'm not a lover of that term,but I will say, so far the
different groups we've looked at, there are certain things that
do jump out as unusual incertain populations.
So that's really interesting.
And then it also willultimately help us decide
whether an intervention isworking if we can move numbers
(04:01):
from outside the healthy rangeback into the healthy range.
Speaker 1 (04:06):
Yeah.
Speaker 2 (04:07):
Yeah.
Speaker 1 (04:07):
Makes a lot of sense to have an anchoring point,
something that we can reference,versus just the kind of system
one like.
Speaker 2 (04:14):
I don't feel good about that, you know, like I saw
that and it doesn't becausethere's so much variability
within that there is a lot ofvariability and trying to tease
apart the variability that isdue to measurement choices that
we make, as opposed tovariability.
That's really there is one ofour current questions.
So there's so much to ask.
(04:37):
I always say there's noshortage of PhD questions for
people to pursue.
Speaker 1 (04:42):
Yeah.
Speaker 2 (04:42):
So inclined.
Speaker 1 (04:44):
Yeah, no, and I love that you've got your your your
hands in this like elbows deep,really going after so many
different things in a veryclinically practical way.
To me, that's one of the thingsthat I appreciate about the
research that you do is I thinkit has a very good translation
to clinicians.
You're not necessarily justlooking at some, some slight
nuance, but it's something thatwe can use to make patient
(05:07):
outcomes better and as aclinical degree, I mean, that's
what matters.
Speaker 2 (05:10):
That's yeah, I hope so.
We really want it to beclinically relevant.
Speaker 1 (05:17):
Yeah, no, I think it's great.
I really appreciate what you'reputting out there.
It sounds like so.
As a researcher, you've done alot of research, you've studied
methodology, you've looked atthreats to validity internally
and externally, and you've reada lot of research too, right,
(05:38):
and so it sounds like one of thethings that you're interested
in is looking at systematicreviews and trying to establish
the rigor of those right or thelet's say I need a fancier word
for this I guess the validity.
Can I still use that term?
Speaker 2 (05:54):
Validity, trustworthiness there you go we
trust it.
Speaker 1 (05:58):
Yeah, let's just.
Speaker 2 (05:58):
Yeah, yeah, I chose this topic to talk about today
because systematic reviews areubiquitous, right?
You probably know that any newdoctoral student it's really one
of the first tasks that wesuggest is to help you define
your question, go and do asystematic review and figure out
(06:22):
what the gap is that you wantto study, review and figure out
what the gap is that you want tostudy and then, at the same
time, they have this position ofprominence on all of those
pyramid diagrams that you see,just Google the pyramid.
Yeah, I mean, they're right atthe top systematic reviews and
meta analyses, as if there'ssome you know holy grail, and I
(06:47):
don't think it's that simple.
I think there are goodsystematic reviews or bad
systematic reviews, and forclinicians who are reading the
literature, it's important toknow how to read them, to figure
out if this review is one thatyou are going to take away as
something that should influenceyour practice.
Speaker 1 (07:10):
Okay, yeah, I think you answered the question I was
just going to ask.
I was going to ask you know theclinical relevance.
But you know that makes totalsense If a study I mean if you
have one study that's purportingto make not a correlation but a
causal relationship betweenyour two variables, and then you
have a systematic review that'strying to find all the studies
(07:32):
that meet their criteria and aresupposedly rigorous and good,
but they're not doing a good jobat that.
But then this is being upheldas a gold standard or just a
good practice.
That becomes a problem.
Speaker 2 (07:45):
It does, and there are so many systematic reviews
out there now, and I think Ibecame sort of more interested
in what makes a review goodversus not good when I started
stumbling across reviews thatcome out around the same time,
that are essentially looking atthe same question and come up
(08:07):
with different answers, or lookat different selections of
articles, and so you start toask why did that group choose to
include this one and excludethat one?
You know which one is correctand I'll tell you.
I'm doing a systematic reviewright now.
(08:27):
We published a review in 2015or 2016 for IDSEE looking at the
effects of texture modificationon physiological measures of
chewing and swallowing, and it'snow 10 years old and so we
(08:49):
decided it would be good toupdate it.
And when we cast our search net,we decided to include
systematic reviews as one sourceof evidence, and there are 150
systematic reviews that made itinto our pile for us to weed
through, and a lot of them aredancing around very similar
(09:11):
questions.
You can ask does texturemodification work for reducing
pneumonia?
And then you can ask doesgiving people free water impact
pneumonia?
And you're just asking twosides of the same.
So I think it's a minefield ofpublications out there, it
(09:35):
becomes really difficult tofigure out your way through and
figure out which ones to trustand to put energy into Sure.
Speaker 1 (09:48):
So yeah, so if clinicians, you know, we
typically in our master'sprograms will have some sort of
a research class, but I wouldargue the regardless of the
depth that's provided, that it'snot something that most of us
walk away from feeling thatconfident in.
So, as clinicians who aren'tprimarily trained in research,
(10:11):
what do you think are some ofthe most important things for us
to be aware of when looking atthe methods to see?
Is this something I can trust?
Speaker 2 (10:19):
Yeah, well, maybe I'll talk through sort of what
I've learned over my timedabbling with systematic reviews
, because I'm not trained as anepidemiologist, I'm not trained
in systematic review methodologyspecifically, but certainly
along the way I've picked it up.
Speaker 1 (10:39):
Yeah.
Speaker 2 (10:41):
And hopefully now I'm doing better reviews than I did
, you know, originally.
So the first thing is that therehas been methodology developed
and that's now consideredstandard best practice.
In systematic reviews we alsonow distinguish between
systematic reviews and scopingreviews, which are less focused
(11:04):
on a really precise question andmeant to characterize a topic,
and for both of those there'ssomething called the PRISMA
statement and PRISMA checklist,which is a best practice
guideline that's widely acceptedas the way to go.
So that is very helpful andcertainly if you're thinking
(11:27):
about doing a review or ifyou're reading a review, you
should see whether they followedthe PRISMA guidance.
There's also registries now ofreviews so you can go and see
whether somebody's currentlyworking on a review and whether
(11:47):
they've registered that.
So there's a registry calledProspero, which is for
systematic reviews, and so ifyou're going to do a review and
you want to register at aProspero, you go in and they ask
you it's like submitting anethics proposal they ask you to
outline all of the plans andsteps of your review and they'll
(12:10):
ask you follow-up questions ifyou aren't clear enough.
So it's an attempt to sort ofmake sure everybody's on the
right path.
It's also a place if you'rethinking of doing a review to
make sure that nobody else isworking on the same question at
exactly the same time?
Speaker 1 (12:26):
Oh nice, even before it's published.
Speaker 2 (12:29):
Right, not everybody does register Some people keep
it secret, but I can tell you,because it's happened to us,
that it's really frustrating tohave a review and to submit it
for publication, and then thereviewers come back and say,
yeah huh, you know, um, somebodyelse published a review on this
(12:52):
exact question a month ago.
How is yours different?
Um, and it becomes much harderto publish your work yeah and on
the scoping review side, um,prospero won't accept scoping
reviews, but Open ScienceFramework will, so that's
another place to look.
Speaker 1 (13:13):
Open Science Framework, Prospero
P-R-O-S-P-E-R-O.
It looks like their website iswwwcrdyorkacuk.
Yes, wwwcrdyorkacuk.
Slash prospero P-R-O-S-P-E-R-O.
Just for anyone who wants tocheck that out.
Speaker 2 (13:34):
It's at the University of York in England
and they may, so they reviewyour protocol before you do it
and then, if they accept it, itgets posted on their registry
there are also now tools thatare available for doing
systematic reviews.
When we did the IDDSI one morethan a decade ago, we had this
(13:56):
crazy Excel file that I tried tomanage with all of the ratings
yeah, all of the ratings and nowthere are softwares that
anybody who has an academicaffiliation can probably use
through their university.
There's one called Covidence,which I find really good, and
there's a newer one called Ryan,which I think is R-A-Y-Y-A-N
(14:22):
and I haven't used it, y-y-a-nand I haven't used it.
I have colleagues who have, andit uses some sort of automated
algorithm to try to weigh therelevance of the articles that
you're looking at, to try tostreamline the task.
So there are choices there, andcertainly the one we're doing
(14:44):
right now in Covidence.
It's enormously helpful to havea platform organizing the work
so you can have lots ofreviewers involved, and this
makes sure that every article isreviewed by two people and it
flags differences of opinion sothat you can then discuss them,
(15:08):
differences of opinion, so thatyou can discuss them.
So those are sort ofinfrastructure pieces behind the
review I didn't mention.
In addition to Prisma, of course, there are guidelines on how to
do systematic reviews that comefrom organizations that
specialize in this.
Probably the most famousorganization is the Cochrane
Review, cochrane Collaboration,and the Cochrane Collaboration
(15:31):
was designed and born to doevidence-based reviews in
medicine, and they have coursesthat people can take.
They have a very strictmethodology and I think one of
the things that's important toknow is that in a Cochrane
review, you only look atrandomized control trials.
(15:53):
That's the only source ofevidence that makes it into the
set, and so that sort of leadsto.
One of the things that I thinkis important to ask as a reader
is what limits did the authorsput on their search strategy,
(16:13):
and do you think those are goodlimits?
Because I this exercise is likecasting a net on the literature
to find all of the articlesthat might be relevant, and
there's a real balance betweenwanting to make sure you don't
miss something.
Speaker 1 (16:32):
Sure.
Speaker 2 (16:35):
And not overwhelming yourself with irrelevant
references, and I think that'sthe most challenging piece.
It's a bit soul-destroyingbecause now we run our searches
in multiple search engines.
We put the search terms in andthen you specify limits.
(16:56):
So for the IDSI search thatwe're doing right now, we're
trying to be reallycomprehensive and we cast the
net across three or four searchengines and we came up over a 10
year timeframe with 66,000articles.
Speaker 1 (17:15):
It's quite a few to filter through green.
Speaker 2 (17:29):
Yeah, it's crazy.
And of those 66,000, about2,200 look like they might be in
the ballpark.
So we had to eliminate 64,000odd articles, which is kind of
tedious work to do.
Oh, absolutely, and certainlynot fun for graduate students
who are starting this, so youcan understand why people put
(17:50):
limits on, like saying, okay,this is too big.
We're only going to look forarticles that are randomized
control trials.
Speaker 1 (17:56):
Yeah.
Speaker 2 (17:58):
Or we're only going to look at articles, or we're
only going to look at articles,and so that 66,000 was for
articles from 2012 forwardrather than from the dawn of
publication, and so you'll seechoices being made.
There's two systematic reviewsthat I found interesting to
compare a few years ago thatwere both around the efficacy of
(18:19):
behavioral interventions fordysphagia.
That were both around theefficacy of behavioral
interventions for dysphagia andone of them had put like a
five-year limit and the otherhad put an 18-month limit.
And so interesting to stop andsay do I think an 18-month limit
(18:42):
is enough to answer my question?
Is there likely to be enoughmaterial published in the last
18 months?
I would say no, but justinteresting?
Speaker 1 (18:51):
I wouldn't think so.
I mean as much as I feel westruggle to find good studies in
the literature that actuallysubstantiate how effective an
exercise is for a specificpathophysiology or whatever
other outcome for swallowing youhad to limit it to a year and a
half.
I mean like if you limit it to20 years you might get some
(19:12):
stuff, but and I know that, Iknow that recency is is
important, but at the same timethat just does seem really over
over.
Speaker 2 (19:20):
Yeah, that seems overly restrictive to me.
Other limits, you'll see, is,you know, only in English.
Or a very common one that Ithink is worth really thinking
carefully about is do you onlylook for peer reviewed
publications or do you also digbeyond that into what we call
(19:40):
the gray literature?
So the gray literature isthings that actually haven't
made it to publication.
So it might include conferenceabstracts, for example, or
trials that you know areunderway but not yet published.
And it's a bit of a slipperyslope, because then you have to
ask why hasn't it made it topublication?
Is that just timing, or isthere a reason why it hasn it
(20:01):
made it to publication?
Is that just timing, or isthere a reason why it hasn't
made it into publication?
So, personally, I tend to stickto peer-reviewed publications
only.
Sure, but those are choicesthat authors make to manage the
job of the search.
To manage the job of the search, then you should look at how
(20:24):
many people were rating and howwere.
Was this done just by oneperson, for example, and or was
it done by more than one person?
And was there a process forcomparing decisions and
resolving any discrepancies?
Because, like it or not, we'reall prone to bias, and so
deciding whether to include ornot include an article sometimes
(20:48):
can pull on those biases.
So it's really important, Ithink, to have a second reader
and to have them have anopportunity to challenge the
decisions of one person.
Speaker 1 (21:02):
Okay.
Especially when you're workingthrough a huge number, you get
tired too Earlier in the day youmight be a little more
stringent than you are later.
It's like oh, it looks good.
I can see that there would be alot of different things that
would influence that process.
So it sounds like, from whatyou're saying, you've got this
(21:25):
idea and coming into asystematic review.
Speaker 2 (21:26):
how broadly you're going to cast your net.
Speaker 1 (21:29):
So like how, yeah, are you just going to do a title
search?
You can do an abstract,abstract search too.
Are you going to look in onejournal or all of these
different journals or searchareas, and then?
So you have that, and then youhave the filtering process.
So within the filtering process, some things that are important
are make sure they're peerreviewed, I mean, that's at
least.
That is not perfect, but it ofcourse establishes, hopefully
(21:52):
some integrity of the particularone you're looking at.
But then also having a checksand balances system for
inter-rater reliability betweentwo judges to minimize bias, is
that?
Speaker 2 (22:03):
my thought following so far.
Yeah, and then one othercomment to make is often people
will update systematic reviewsat a given frequency and I think
it's important to stop and sayhow likely is it there's new
information in the timeframesince the last review was done,
(22:24):
and here your filters come intoquestion as well.
So there's an example I like touse here is there's a series of
systematic reviews and bestpractice guidelines that fall
out of those that were done by agroup in Denmark looking at the
effectiveness of thickenedliquids for managing, you know,
(22:47):
pneumonia and other downstreamconsequences, and they made a
decision to only look atrandomized, controlled trials.
So the set is pretty small.
And in their first iterationthey found the big study, the
Logum and Robbins Protocol 201studies that were published in
(23:09):
2008.
And that was really one biggrant with a couple of
publications.
And we probably all know thestory that in direct comparison,
within the video fluoroscopythere was less aspiration on the
thicker consistencies, but withuse over time there wasn't a
clear answer and, if anything,randomization of people who are
(23:33):
aspirating to thickened liquidsturned out to be unadvisable
because there were some nastydownstream outcomes
irreplaceable because there weresome nasty downstream outcomes.
So that was their first paperand they concluded it wasn't
strong evidence.
And then three or four yearslater they said let's do this
again.
And I guess the first thing Iwould say is I don't think there
(23:56):
are secret randomized controltrials of big questions hiding
in the literature to find wewould all know if there was a
big study happening.
We could look at something likeclinicaltrialsgov to see if it
was happening.
But they don't appear to havedone that.
So they did the whole exerciseover again and they found the
(24:19):
same two studies and then theyfound one more which was a tiny
study in like 12 or 20 peoplewith a particular etiology that
wasn't strong enough to shiftthe needle at all on the finding
.
And so they published that againand then three or four years
(24:41):
later they cast the net againand exactly the same thing
happened.
They found the Logerman andRobbins papers and one or two
more tiny papers and so evidenceon that question hasn't been
moving because nobody is doing abig study that's randomized and
(25:02):
properly controlled and theexercise of going hunting for it
is a bit futile.
So I think you need to have agood question and to warrant the
effort that goes into it.
I think, make sure nobody elseis already doing it and make
sure that you have something topull, because I've also seen
people presenting reallybeautiful systematic reviews on
(25:27):
a lovely, clear, focusedquestion and they cast their net
and they do all their screeningand at the end of the day they
get zero studies that arerelevant to synthesize and
that's just a waste ofeverybody's time.
It's entirely predictable thata systematic review conclusion
(25:48):
statement will say there'sinsufficient evidence to answer
this question, but to findnothing is a waste of time.
Speaker 1 (26:00):
Yeah, yeah, it's almost.
I mean, we have a lot of valuefor systematic reviews
supposedly being at the top ofthis, this pyramid we look at as
far as levels of evidence go,and I'm trying to think of an
analogy, an analogy to compareit to, because if I mean, if you
don't have the pieces that arenecessary in order to get a good
systematic review, then maybeyou should be working on
(26:20):
designing a good randomizedcontrol trial for the question
rather than pursuing asystematic review.
It almost is like you know,learning to run before you can
walk.
Speaker 2 (26:28):
Yeah, and I do think in dysphagia we struggle because
we know that there's thisevidence-based framework in
medicine, we know that there'sincredible value on randomized
control trials.
But they are so hard to do andin order to get large numbers
(26:53):
for a randomized control trialyou have to decide that a large
number of people are similar andequally likely to benefit or
not benefit from theintervention you're studying.
And I struggle with that as aclinician because it's in direct
(27:17):
tension with the idea that wewant to do personalized
mechanism-specific therapy fordysphagia.
And so you'll see these bigstudies that say we recruited, I
don't know, 100 people withdysphagia post-stroke.
That is not to me a remotelyhomogeneous population.
Speaker 1 (27:43):
Stroke could be anywhere.
Speaker 2 (27:45):
It could be anywhere, the dysphagia could look
different.
I just really reject the ideathat all of those people are
equally likely to benefit from aprescribed uniform therapy.
X.
Speaker 1 (27:57):
No, I totally.
I mean, if you think of thebrain as the controlled system,
you haven't been very specificat all in describing dysphagia.
It's just you know the etiology, so from a neurological cause,
so maybe so you got that.
But it's kind of like lumpingall the dysarthria together.
You could have a flaccid andyou could have a spastic and
it's like, well, you know, thetreatment's gonna work
(28:19):
differently from from flaccidyeah, so, yeah.
Speaker 2 (28:23):
So one of the consequences of this is when you
actually go to places like thecochran collaboration and see
what they've managed to sayabout evidence in our field,
they don't find much, and whatthey do find isn't about
behavioral interventions whichare customized to the patient.
(28:44):
They're about things likeacupuncture or magnetic,
trans-cranial magneticstimulation.
Actually, I would say I'msurprised, in the review that
we're doing right now, about theproportion of studies that are
in the pile that have to do withsomething like transcranial or
(29:07):
rapid TMS.
There's a lot, and the outcomesmight not be measured in ways
that we would like, but it'sjust interesting that there's
such a large body of literature,because I don't think that
doesn't fit with myunderstanding of the kind of
work we're doing.
Speaker 1 (29:26):
Yeah, you said something a second ago and I'm
going to paraphrase.
I'm going to butcher, but thequestions might not be the ones
that we would like.
I believe you said something tothat effect.
That makes me think of, justoverall, if we're asking the
right questions as far asresearch goes, or if we're
looking at the right parameters.
(29:46):
So, in one of the studies youmentioned, as far as the
influence of thickened liquidson different bolus flow
parameters, penetration,aspiration, et cetera, well, I
mean I hate to throw the termcommon sense out there, but if
somebody because I mean what iscommon sense?
(30:07):
Right, but get away from systemtwo a little bit, or system one
a little bit, but withthickened liquids, okay, right,
I mean it might reduce that.
But is that the right questionto ask?
It might reduce airway invasion.
It probably will.
Probably will Someone'saspirating liquids.
You give them nectar, thickliquids, they're probably less
likely to aspirate, unless maybeit's if it's after the swallow.
That's a different story, buttypically, yeah, but I don't
(30:28):
know if that's the rightquestion.
Why do we care about aspiration?
We care about it because wedon't want anyone to asphyxiate
and they can't ventilate and getair in and out and we don't
want it to affect externalrespiration gas exchange between
the alveoli and the capillariesin some way.
And so there's our you know,our pneumonia or whatever else
we're looking at.
(30:49):
So those, to me, are they'reasking the right questions and
that's so important because youcan substantiate a relationship
and you might get a really goodrelationship and say, yeah,
thicken liquids reduceaspiration.
That's great, but it's like, isthat where our focus should be?
It's a good study, but it movesour focus, I think, away from
the big picture outcomes andpotentially doing something that
(31:11):
has potential to be detrimentalin the right patient
populations.
I don't know, that's a soapboxfor me.
Speaker 2 (31:15):
Yeah, it is a soapbox topic and it's a really
controversial one right now.
I've seen arguments in bothways.
I'm actually more on the sideof understanding the
physiological effect of textureand consistency on swallowing,
(31:39):
and I'm very interested, ofcourse, in the long-term
outcomes of addressingsomebody's dysphagia
appropriately.
But to me there are so manyother things that need to be
controlled.
I don't think that texturemodification in and of itself is
enough to mitigate thedifferent mechanisms that
(32:03):
contribute to respiratoryoutcomes or, for that matter,
nutritional and hydrationaloutcomes.
So I think we need to becareful and there's a lot of
papers that ignore thoseconfounding relationships.
So I've always said that Idon't think it's fair to
(32:23):
evaluate a speech pathologyintervention using an outcome
like pneumonia, because I don'tthink we're that powerful.
But, yeah, I do think that weneed to understand that the pros
and cons of thickening and andit's not, it's not always a
(32:44):
beneficial intervention and anddefinitely it's over prescribed,
and we we need to fight forbetter assessment before we
recommend it.
In my opinion, yeah, that yeah,that makes.
Speaker 1 (32:58):
No, that makes a lot of sense to me.
One question that I guess whatcomes out of that is I.
So it's, it's, it'smulti-variate, right, and even
if you, if you simplify it tothe three pillars which there's,
of course, more to it than thethree pillars, you know immune
system status, laryngeal valveintegrity or presence of
(33:19):
aspiration whatever, and oralhygiene even if you just look at
those three things, it showsthat it's multivariate and that
aspiration is probably the leastimportant one.
So the idea that, like, yeah,we're not really that powerful
to control this with, just withthickening liquids or whatever
it is that would help to reducethe bolus and, wow, help to
(33:42):
reduce the bolus and wow, I'mhaving a moment.
Speaker 2 (33:45):
I like to turn the question on its head and so,
rather than saying, do I thinkthickened liquids are the right
thing for this patient and why?
I think the place where I findmyself most challenged is in
asking am I comfortable notconsidering an intervention to
(34:05):
reduce the opportunity foraspirating?
Am I okay with what people callthe risk element?
Here and for some people youmight arrive at a point in
discussion with the patient andthe family and consideration of
all of those elements, that somedegree of informed risk is
(34:29):
something that people arecomfortable with.
But there are certainly in mypatient's caseload history
people where I could not bringmyself to sort of cavalierly say
, go ahead and aspirate, and soI think it's that dynamic and
there, if I know that a changein diet texture limits that
(34:55):
opportunity for transportingthings into the airway, then I
feel I need to explain that andprobably recommend it, Keeping
in mind that of course, peopleaspirate outside the context of
eating and drinking and I thinkmouth care is a really important
part of this equation as well.
Speaker 1 (35:16):
Yeah, no, absolutely.
I think I don't mean todiscredit the importance of
understanding the relationshipof diet textures on bolus flow
parameters.
I think it's important.
I just I also think there's somany other questions within that
to ask too.
Why do we care about this?
(35:37):
But it's kind of like it'sbuilding, they're building
blocks.
Speaker 2 (35:40):
You're building one thing upon the other, upon the
other, and I think you have toknow the answer to these
questions yeah mentioning beforeyeah, it has to be a thorough,
careful consideration, and Ithink I always, I sure hope that
the people who are listeninghave themselves drunk thickened
(36:02):
liquids.
Speaker 1 (36:03):
Oh yeah.
Speaker 2 (36:04):
And you know, spend a day on texture modification and
thickened liquids and thinkabout the impact that that has.
It's huge, and so we should useit wisely and cautiously.
And the other thing you know ifyou want a soapbox is we should
revisit it regularly.
We should give patients theopportunity to return to more
(36:27):
normal eating and drinking atthe earliest possible
opportunity if we can.
So I joke here about in Canada.
we don't have mobile videofluoroscopy vans or mobile
endoscopy vans, but in my labit's kind of a joke.
But it's not really a joke.
(36:48):
We dream of, you know drivingone of these around and finding
all the people who are stuck outthere on enteral feeding or on
texture-modified diets that theyno longer need, who simply
haven't had an opportunity to bere -evaluated.
Speaker 1 (37:07):
Yeah, yeah, not as assuming that they're going to
stay the same.
Speaker 2 (37:12):
Exactly Giving them the opportunity for change.
Speaker 1 (37:14):
No, that makes a whole lot of sense With this
idea of looking at the integrityof systematic reviews, because
it helps, you know, if we'rethinking of the idea of showing
a relationship between atreatment and an outcome within
a controlled setting to see if,well, maybe it will apply to to
(37:37):
our patients, like, obviously,it's going to be incredibly
important that we have faith inthat A lot.
It does sound like.
There are a lot of areas,though, where there can be, oh,
where they can not go wrong, butwhere they may not be as
trustworthy as we would likethem to be, and I know you've
(37:57):
discussed some of that, and whatI would love to do is, after
this, we can chat, and I want tomake sure I write down some of
these resources to be able topoint people to.
On the other side, I want to, Iwould love to hear what you
think is really promising, orwhat you're you're excited about
, like, how are we moving in ain a good direction?
Cause, in my mind, like there isa lot to be critical of as far
(38:21):
as, like these are things we cando better and these are things
we need to be wary of.
At the same time like I'mtrying to be really mindful of
that because I can go really farthat direction.
So I try to still infuse hopeinto things.
So, like what do you see, howare we moving in like the right
direction in this regard?
I mean, I think just this theawareness that people are
getting is moving in the rightdirection, because then they can
be better filters and asclinicians in applying this.
(38:44):
But maybe from the back end,the research side what are you?
What are you excited?
Speaker 2 (38:47):
Well, I do.
I do think the emergence ofguidelines about how to do this
and tools with which to do it isis moving us in the right
direction.
One of the steps we haven'tdiscussed yet is that once you
get your set of articles thatyou think are relevant and meet
your criteria, there's a reallyimportant step in terms of
(39:10):
evaluating the quality of thosearticles.
And at the beginning of thepandemic, I was part of a
journal club that formed reallyjust to stay connected.
So there were six labs, somyself and Sonia Malfenter, who
you mentioned, and AshwiniNamasivam McDonald, who both of
those are my previous doctoralstudents.
(39:34):
And then we pulled in some ofour collaborators, so Rebecca
Afu at Dalhousie University herein Canada and Nicole
Rogaspuglia at Madison Wisconsinand Emily Plowman, and so we
had this journal club and wethought we would get all our
students together and haveregular meetings, and we found
(39:56):
ourselves inevitably, I think,reviewing systematic reviews in
Swallowing, and very quickly thetrainees started to say, yeah,
but there's no common method forevaluating the quality of these
articles from a dysphagiaperspective.
(40:17):
There are tools for evaluatingquality broadly, like the
Cochrane risk of bias tool, andthere are tools that look at
single subject design, but wewere finding that very commonly
and this is still true somebodywould say something like we did
a video fluoroscopy and thenthey wouldn't tell you anything
(40:41):
about how they did that videofluoroscopy things that matter
to the transparency of theirmethods yeah, the rigor and the
transparency just wasn'treported.
So, how many boluses, whattextures were they?
What volumes were they?
Um, what was the barium thatwas used?
(41:02):
What was the frame rate used?
Those kinds of methodologicalconsiderations.
And that video fluoroscopy waslacking.
This Endoscopy was also lacking.
This and so the things that ourtrainees and I should say that
trainees who are doing doctoraldegrees have really sharp
(41:25):
critical teeth, you know,they're trained to go in and
find all the things that arewrong.
And so these methodologicalshortcomings in terms of
reporting, but maybe also interms of how the studies were
actually done, were coming out,and the need for a framework to
critically appraise the qualityof the dysphagia methods came
(41:48):
out of this journal club, and sowe built a critical appraisal
tool and it's public domain.
It's called the FrontiersFramework.
It's httpswwwfrontiersframeworkcom.
I think I'll check that for youand in a beta version it will
(42:10):
be refined over time.
But this group of traineesdesigned the questions that they
felt we needed to be asking andchecking.
So the vision is that it canwork in this exercise of
reviewing the quality of thingsyou're reading, so you can go
check, check, check.
They did or they didn't reportthis, but it's also the vision
(42:36):
is.
It's a tool that you could useif you're designing a study.
You could look at this andthink about all of the things
you need to plan for or, whenyou're writing your own article,
all of the things to check thatyou've included.
And it's quite a humblingexercise to take one of your own
historical articles and run itthrough this critical appraisal
(42:58):
tool and realize all the thingsyou could have reported better
the tool and realize all thethings you could have reported
better.
Speaker 1 (43:07):
Well, I mean, what I like about it is it seems to
have stemmed from a need thatwas made very clear during, like
when you're trying to discussthese articles, that it was kind
of in the forefront of yourmind.
We have these general tools tolook at systematic reviews, but
nothing to evaluate from theperspective of dysphagia.
Speaker 2 (43:23):
So I don't know, and what we found was I think we
looked at three systematicreviews early in the pandemic in
that first few weeks and wefound that all three of these
sets of authors had come up withtheir own tools to address this
short, but they were limited toa particular focus, so we
wanted something a bit broader.
Yeah, so I'm quite excitedabout it.
(43:47):
We will have a series ofarticles coming out in a special
forum in AJSLP later this yearintroducing the tool and the
different themes in the tool,because there are different
sections and when you there'salso a web-based interface.
(44:09):
So when you go into it it askssome basic questions and then it
limits the set.
So if you've only done videofluoroscopy, it'll bring up that
section, but it won't bring upanother section.
That's not relevant.
So what we're hoping is thatpeople will start using it and
give us feedback on it and overtime that will evolve.
(44:31):
I think in a couple of years wethink it'll be time to pull a
consensus panel together to lookat feedback and refine the tool
, but then that it will becomesomething that's a resource
that's useful.
So I've had some fun using itin some workshops with
clinicians just to explore someselected articles, and it's
(44:57):
fascinating.
Actually, the most recent timeI did this, we were looking at
thick and liquids as a topic andso we pulled in Protocol 201
articles as two of the articlesto appraise and so not to say
that the methods weren't donewell, but there are gaps in the
(45:28):
reporting of how those videofluoroscopies were done.
That I think would surprisepeople today and that if we were
doing it again, we would wantto report better.
Speaker 1 (45:38):
Yeah, there are a couple of things that I believe
are really beneficial that havecome from this.
So one you've provided you alltogether have collaborated and
provided this method to evaluateso that we have a better idea
that we're not comparing applesto oranges.
We have a better idea thatwe're we're really measuring
what we think we're measuring.
Speaker 2 (45:58):
Yeah.
Speaker 1 (45:58):
So that's going to help, but also, I think that
this has potential to help inthe production of research too,
because you had mentioned thatother individuals are making
their own, so they're taking allthis time and all this energy
to make their own.
So, but if you have this, thenthat's one less thing they have
to worry about.
They can really focus on theirstudy in other ways and make it
perhaps a little easier to getthings done, which that's
(46:18):
fantastic too.
Speaker 2 (46:19):
Yeah, we hope so.
One of the questions thereviewers asked us is are you
reinventing the wheel Right?
So that people may know?
There's something called theequator network, which is a
place where guidelines live, andso, in order to address the
(46:40):
reviewers' concerns, we also dida scoping review of all of the
guidelines that are housed atthe Equator Network to find out
which of them, if any of them,addressed issues of quality and
rigor and transparency relevantfor dysphagia research.
Want to guess how many we found?
Speaker 1 (47:07):
want to guess how many we found, uh oh, and do the
ones that were just used?
Speaker 2 (47:09):
in those articles count, if not?
I'm going to say zero, zero,zero, zero essentially, we found
that all of these guidelinesare worthwhile, um, but they're
not specific enough to the kindsof things that matter to us as
dysphagia clinicians, and so youneed both, really.
And, yeah, so that that articlewill be coming out as part of
this series, and and that mightbe useful for people too,
(47:33):
because what we did was wemapped the five I think it was
542 guidelines that are werewarehoused at the equator
network as of the date that wedid it, that were warehoused at
the Equator Network as of thedate that we did it, and we
profiled them to say which onesaddress topics that might be
interesting to speech, languagepathologists and dysphagia
researchers.
So that's there, too, to pointpeople to things.
(47:57):
So we don't reinvent the wheel.
Speaker 1 (47:59):
Moving forward, Sure Well, that sounds great, it
sounds very practical.
It complements something thatis already there, but it
provides a deeper level ofspecificity for a very specific
topic.
Speaker 2 (48:12):
Yeah, yeah, I hope so .
Speaker 1 (48:14):
Yeah.
Speaker 2 (48:15):
And I just I want to say again that a huge amount of
the work that's been done aroundthe Frontiers framework and
that Equator Network review wasdone by trainees, and so they
get the authorships and deservethe credit.
Speaker 1 (48:33):
That's excellent.
That is great.
Well, there is always so muchto talk about.
I appreciate everything thatyou've brought up and you
mentioned a number of resourcesthat I want to double check to
make sure I write for thedescription, because I mean,
this is I.
We were, before we startedrecording, talking about some of
the different purposes of thepodcast, and it's one, you know,
(48:56):
to get conversation going, toget people talking about things
that are important, and anotherone is to reduce some of the
power distance between, orperceived power distance, maybe
between clinicians and and thosewho are doing research and
tenure track positions or aretenured at their university,
because sometimes it can beintimidating.
But what I get from this is Imean, everyone has just been so
(49:20):
open to conversation andwelcoming.
I mean you're so people arepassionate about what they do
and they just seem to welcomediscussion.
So I think this kind ofshowcases that.
There was a third thing, ohyeah, the resources too.
Right, so we're not going toget everything on here, but it's
a starting point forconversation If people want to
continue the conversation.
They can check out theseresources or, you know, reach
(49:42):
out any number of things, butit's a beginning.
Speaker 2 (49:45):
Yeah, and if I could plant a bit of an ad here.
I think, you know, once upon atime I was a clinician who was
thinking about research and Iprobably did that.
You know.
Should I do a PhD question fouror five times before the stars
aligned for me?
Speaker 1 (50:04):
I do it about once a week.
Speaker 2 (50:07):
But I had a habit at the time, and I don't know how
open people would be to thishabit, but whenever I went
somewhere, to a professionaldevelopment meeting, I would see
if the local dysphagia guruwould have me for a visit.
And, as the story goes, susanLangmore was one of those people
(50:28):
and she very graciously had mecome and spend a day at her
clinic, and in the course ofthat conversation she said you
should go to dysphagia researchsociety meeting, which I had
never done.
And so I decided sure thatsounds like fun, I'll go.
And so I went along as aclinician and it changed my life
(50:52):
.
I immediately was hooked, andthe opportunity to speak to
established researchers in afairly intimate conference is
extraordinary and to networkwith other people in the field,
and so I'd really love toencourage people to come next
(51:14):
year.
We're going to be inPhiladelphia March 25th to 28th.
I think the networking thathappens at those meetings is
extraordinary and profound.
And so come, we'd love to haveyou, and it is a place where you
can go up to the big names andsay hi and hopefully we'll be
(51:37):
welcoming and interested to meetpeople.
Speaker 1 (51:41):
Yeah, no, I echo that 100%.
Actually, this was the yearwhen it was in San Francisco and
it was DRS and the WorldDysphagia Summit.
Due to some differentparameters, I just attended the
World Dysphagia Summit part ofit and it was very sad to miss
DRS, and this year I was verysad to miss it.
But there is the networking andthe conversation.
(52:05):
Those things are so importantbecause it helps to calibrate us
.
So we're talking about theright things.
That exposes us to differentperspectives and different
questions that we didn't evenknow were out there.
And just within the idea oflearning, okay, you can listen
to a lecture, you can read atextbook, but you really get
into it when you start applyingit in conversation and you get
(52:26):
excited about it and you want tolearn about it.
So you remember it.
There's so much of those thingsthat go on behind the scenes
and I think things like DRS arefantastic in that regard because
it helps to infuse passionwithin everybody and really get
the conversation going.
So, yeah, thank you for.
Speaker 2 (52:44):
And you can also see the battles being fought.
You know, but the debates likeand and think about how people
are pushing the envelope and andexpanding what we know, and I
love that.
I mean you can watch peoplelike me getting up and asking
(53:05):
challenging questions and seehow that goes.
So I think it's really aspecial thing.
It's totally different thangoing to a more clinically
focused meeting, but it doeshave clinical implications and
relevance.
So, yeah, hopefully some ofyour audience will think about
(53:27):
coming.
Speaker 1 (53:28):
Well, I'm hoping to be there.
So, yeah, if you all do end upcoming and are influenced or
were influenced by this episode,come and tap our shoulders, let
us know.
That'd be really cool.
But anyway, thank you so muchfor everything.
Is there anything else thatyou'd like to leave people with
before we wrap up?
Speaker 2 (53:48):
just like to encourage people to keep asking
questions, and the thing I thinkI love most about this field is
the opportunity to keeplearning for sure and
challenging what we know for thebenefit Ultimately, we hope of
our patients.
Speaker 1 (54:08):
Yeah, yeah, I still feel like we're kind of in the
pioneer stage of of.
Speaker 2 (54:11):
We are.
It's an early stage of ourfield.
Speaker 1 (54:15):
So yeah, it's exciting to to at the
opportunity to have an influenceon that.
It's super cool, so yeahabsolutely.
Asking questions.
All right, well, thank you somuch, dr Katrina Steele.
We will include some of theresources that were mentioned
today within the description forthis podcast episode.
That can be found atswallowthegapcom slash podcast
(54:36):
or any of the descriptions onApple podcasts and whatnot.
But thank you so much forjoining and we hope to see you
at VRS.
I hope to be there.
Speaker 2 (54:44):
My pleasure.
Speaker 1 (54:53):
Have a great week.
That brings to close anotherepisode of Swallow the Gap.
A huge thanks to Dr KatrinaSteele for joining us today.
Please see the episodedescription for some resources
that are pertinent to today'scontent, and also see the
episode description for moreinformation from Tim's Medical,
who graciously sponsored thisepisode and will be featuring
Aspect C and upcoming releasesof Tim's MVP in 2025, following
(55:15):
close collaboration with theSwallowing Rehabilitation
Research Laboratory.
For updates on Tim's MVPreleases, follow Tim's Medical
on social media or sign up foremail notifications at
wwwtimscom.
That's T-I-M-S dot com.
I just recorded a fun episodewith Dr Janina Vilmskota from
the Medical University of SouthCarolina.
(55:35):
That's very neuro-focused andit'll be coming out soon, so
keep an eye open for that.
There are several events comingup in the new year.
Hope to see you around for someof those and, either way, thank
you so much for being.
Today's episode of Swallow the Gap is sponsored by
Tim's Medical.
The Tim's Medical team isexcited to announce that Aspect
C will be included in upcomingreleases of Tim's MVP in 2025,
following close collaborationwith the Swallowing
Rehabilitation ResearchLaboratory, which was actually
founded by today's guest.
Hey everybody, Today I have DrKatrina Steele from the Kite
(00:21):
Research Institute and thecurrent president of the
Dysphagia Research Society.
Welcome, Thank you for joiningme.
Speaker 2 (00:27):
Thank you, tim, it's a pleasure.
Speaker 1 (00:28):
Yeah, absolutely.
Is there anything, before weget into this topic of interest,
that you wanted to tell peopleabout yourselves right now?
Speaker 2 (00:38):
Sure, well, I can start with just a little bit of
background.
So I trained as a speechpathologist in the early
nineties and worked clinicallyfor about 10 years.
I don't think I knew we diddysphagia before I went to do my
degree.
I thought I would be an aphasiaclinician and then my final
(01:02):
clinical placement was indysphagia and I fell in love
with it.
And then my first clinicalposition was in a home for the
aged, where the most commonreason for referral was
dysphagia.
And I've ever since, and aboutafter seven or eight years of
(01:23):
clinical practice, I wasfrustrated, mainly because I
loved all of the work we woulddo about diagnosis and I loved
fluoroscopy and we would put somuch effort into it.
And I felt that after all ofthat, we had one generic
intervention we were offering,which was pureed foods and
(01:46):
thickened liquids, and I wasfrustrated by that and inspired
by people at the time, likeMaggie Lee Huckabee, who were
doing rehabilitative work, andso that was really what drove me
back to do my PhD me back to domy PhD and I was fortunate to
(02:13):
get a grant just at the end ofmy PhD, and I've been now doing
this research for 20 years andlove doing it, yeah, and you put
out some very helpful stuff.
Speaker 1 (02:21):
I don't know how many times and I should probably
update what I'm referencing howmany times I referenced mole
thinner and steel.
As far as the variability ofswallowing, you know, highway
movement, of timing measures andthose types of things.
I think that's fantasticbecause it is my opinion that we
over-diagnose dysphagia and weover-restrict, and so I think
(02:42):
that's really helpful to havethat anchoring point to be like
well, you know, actually it'sokay that it initiated in the
pure form sinuses, because ifyou, you know, frame by frame
and time it, there was no, youknow, there are no adverse
outcomes and that's within atypical range that that sort of
thing too.
Speaker 2 (02:57):
So I think, yeah, I appreciate it.
So the you know, this theme ofwhat's normal or what is typical
has really become a focus ofour work over the last decade,
starting with Sonia'sdissertation really, and we're,
as you may know, we're trying tocharacterize reference values
(03:18):
across the IDSEE levels up toextremely thick, primarily in
healthy people on videofluoroscopy.
It's a big job and then also tolook in patient populations and
one of the big questions therewill be are there characteristic
profiles or people use the wordphenotype?
(03:38):
I'm not a lover of that term,but I will say, so far the
different groups we've looked at, there are certain things that
do jump out as unusual incertain populations.
So that's really interesting.
And then it also willultimately help us decide
whether an intervention isworking if we can move numbers
(04:01):
from outside the healthy rangeback into the healthy range.
Speaker 1 (04:06):
Yeah.
Speaker 2 (04:07):
Yeah.
Speaker 1 (04:07):
Makes a lot of sense to have an anchoring point,
something that we can reference,versus just the kind of system
one like.
Speaker 2 (04:14):
I don't feel good about that, you know, like I saw
that and it doesn't becausethere's so much variability
within that there is a lot ofvariability and trying to tease
apart the variability that isdue to measurement choices that
we make, as opposed tovariability.
That's really there is one ofour current questions.
So there's so much to ask.
(04:37):
I always say there's noshortage of PhD questions for
people to pursue.
Speaker 1 (04:42):
Yeah.
Speaker 2 (04:42):
So inclined.
Speaker 1 (04:44):
Yeah, no, and I love that you've got your your your
hands in this like elbows deep,really going after so many
different things in a veryclinically practical way.
To me, that's one of the thingsthat I appreciate about the
research that you do is I thinkit has a very good translation
to clinicians.
You're not necessarily justlooking at some, some slight
nuance, but it's something thatwe can use to make patient
(05:07):
outcomes better and as aclinical degree, I mean, that's
what matters.
Speaker 2 (05:10):
That's yeah, I hope so.
We really want it to beclinically relevant.
Speaker 1 (05:17):
Yeah, no, I think it's great.
I really appreciate what you'reputting out there.
It sounds like so.
As a researcher, you've done alot of research, you've studied
methodology, you've looked atthreats to validity internally
and externally, and you've reada lot of research too, right,
(05:38):
and so it sounds like one of thethings that you're interested
in is looking at systematicreviews and trying to establish
the rigor of those right or thelet's say I need a fancier word
for this I guess the validity.
Can I still use that term?
Speaker 2 (05:54):
Validity, trustworthiness there you go we
trust it.
Speaker 1 (05:58):
Yeah, let's just.
Speaker 2 (05:58):
Yeah, yeah, I chose this topic to talk about today
because systematic reviews areubiquitous, right?
You probably know that any newdoctoral student it's really one
of the first tasks that wesuggest is to help you define
your question, go and do asystematic review and figure out
(06:22):
what the gap is that you wantto study, review and figure out
what the gap is that you want tostudy and then, at the same
time, they have this position ofprominence on all of those
pyramid diagrams that you see,just Google the pyramid.
Yeah, I mean, they're right atthe top systematic reviews and
meta analyses, as if there'ssome you know holy grail, and I
(06:47):
don't think it's that simple.
I think there are goodsystematic reviews or bad
systematic reviews, and forclinicians who are reading the
literature, it's important toknow how to read them, to figure
out if this review is one thatyou are going to take away as
something that should influenceyour practice.
Speaker 1 (07:10):
Okay, yeah, I think you answered the question I was
just going to ask.
I was going to ask you know theclinical relevance.
But you know that makes totalsense If a study I mean if you
have one study that's purportingto make not a correlation but a
causal relationship betweenyour two variables, and then you
have a systematic review that'strying to find all the studies
(07:32):
that meet their criteria and aresupposedly rigorous and good,
but they're not doing a good jobat that.
But then this is being upheldas a gold standard or just a
good practice.
That becomes a problem.
Speaker 2 (07:45):
It does, and there are so many systematic reviews
out there now, and I think Ibecame sort of more interested
in what makes a review goodversus not good when I started
stumbling across reviews thatcome out around the same time,
that are essentially looking atthe same question and come up
(08:07):
with different answers, or lookat different selections of
articles, and so you start toask why did that group choose to
include this one and excludethat one?
You know which one is correctand I'll tell you.
I'm doing a systematic reviewright now.
(08:27):
We published a review in 2015or 2016 for IDSEE looking at the
effects of texture modificationon physiological measures of
chewing and swallowing, and it'snow 10 years old and so we
(08:49):
decided it would be good toupdate it.
And when we cast our search net,we decided to include
systematic reviews as one sourceof evidence, and there are 150
systematic reviews that made itinto our pile for us to weed
through, and a lot of them aredancing around very similar
(09:11):
questions.
You can ask does texturemodification work for reducing
pneumonia?
And then you can ask doesgiving people free water impact
pneumonia?
And you're just asking twosides of the same.
So I think it's a minefield ofpublications out there, it
(09:35):
becomes really difficult tofigure out your way through and
figure out which ones to trustand to put energy into Sure.
Speaker 1 (09:48):
So yeah, so if clinicians, you know, we
typically in our master'sprograms will have some sort of
a research class, but I wouldargue the regardless of the
depth that's provided, that it'snot something that most of us
walk away from feeling thatconfident in.
So, as clinicians who aren'tprimarily trained in research,
(10:11):
what do you think are some ofthe most important things for us
to be aware of when looking atthe methods to see?
Is this something I can trust?
Speaker 2 (10:19):
Yeah, well, maybe I'll talk through sort of what
I've learned over my timedabbling with systematic reviews
, because I'm not trained as anepidemiologist, I'm not trained
in systematic review methodologyspecifically, but certainly
along the way I've picked it up.
Speaker 1 (10:39):
Yeah.
Speaker 2 (10:41):
And hopefully now I'm doing better reviews than I did
, you know, originally.
So the first thing is that therehas been methodology developed
and that's now consideredstandard best practice.
In systematic reviews we alsonow distinguish between
systematic reviews and scopingreviews, which are less focused
(11:04):
on a really precise question andmeant to characterize a topic,
and for both of those there'ssomething called the PRISMA
statement and PRISMA checklist,which is a best practice
guideline that's widely acceptedas the way to go.
So that is very helpful andcertainly if you're thinking
(11:27):
about doing a review or ifyou're reading a review, you
should see whether they followedthe PRISMA guidance.
There's also registries now ofreviews so you can go and see
whether somebody's currentlyworking on a review and whether
(11:47):
they've registered that.
So there's a registry calledProspero, which is for
systematic reviews, and so ifyou're going to do a review and
you want to register at aProspero, you go in and they ask
you it's like submitting anethics proposal they ask you to
outline all of the plans andsteps of your review and they'll
(12:10):
ask you follow-up questions ifyou aren't clear enough.
So it's an attempt to sort ofmake sure everybody's on the
right path.
It's also a place if you'rethinking of doing a review to
make sure that nobody else isworking on the same question at
exactly the same time?
Speaker 1 (12:26):
Oh nice, even before it's published.
Speaker 2 (12:29):
Right, not everybody does register Some people keep
it secret, but I can tell you,because it's happened to us,
that it's really frustrating tohave a review and to submit it
for publication, and then thereviewers come back and say,
yeah huh, you know, um, somebodyelse published a review on this
(12:52):
exact question a month ago.
How is yours different?
Um, and it becomes much harderto publish your work yeah and on
the scoping review side, um,prospero won't accept scoping
reviews, but Open ScienceFramework will, so that's
another place to look.
Speaker 1 (13:13):
Open Science Framework, Prospero
P-R-O-S-P-E-R-O.
It looks like their website iswwwcrdyorkacuk.
Yes, wwwcrdyorkacuk.
Slash prospero P-R-O-S-P-E-R-O.
Just for anyone who wants tocheck that out.
Speaker 2 (13:34):
It's at the University of York in England
and they may, so they reviewyour protocol before you do it
and then, if they accept it, itgets posted on their registry
there are also now tools thatare available for doing
systematic reviews.
When we did the IDDSI one morethan a decade ago, we had this
(13:56):
crazy Excel file that I tried tomanage with all of the ratings
yeah, all of the ratings and nowthere are softwares that
anybody who has an academicaffiliation can probably use
through their university.
There's one called Covidence,which I find really good, and
there's a newer one called Ryan,which I think is R-A-Y-Y-A-N
(14:22):
and I haven't used it, y-y-a-nand I haven't used it.
I have colleagues who have, andit uses some sort of automated
algorithm to try to weigh therelevance of the articles that
you're looking at, to try tostreamline the task.
So there are choices there, andcertainly the one we're doing
(14:44):
right now in Covidence.
It's enormously helpful to havea platform organizing the work
so you can have lots ofreviewers involved, and this
makes sure that every article isreviewed by two people and it
flags differences of opinion sothat you can then discuss them,
(15:08):
differences of opinion, so thatyou can discuss them.
So those are sort ofinfrastructure pieces behind the
review I didn't mention.
In addition to Prisma, of course, there are guidelines on how to
do systematic reviews that comefrom organizations that
specialize in this.
Probably the most famousorganization is the Cochrane
Review, cochrane Collaboration,and the Cochrane Collaboration
(15:31):
was designed and born to doevidence-based reviews in
medicine, and they have coursesthat people can take.
They have a very strictmethodology and I think one of
the things that's important toknow is that in a Cochrane
review, you only look atrandomized control trials.
(15:53):
That's the only source ofevidence that makes it into the
set, and so that sort of leadsto.
One of the things that I thinkis important to ask as a reader
is what limits did the authorsput on their search strategy,
(16:13):
and do you think those are goodlimits?
Because I this exercise is likecasting a net on the literature
to find all of the articlesthat might be relevant, and
there's a real balance betweenwanting to make sure you don't
miss something.
Speaker 1 (16:32):
Sure.
Speaker 2 (16:35):
And not overwhelming yourself with irrelevant
references, and I think that'sthe most challenging piece.
It's a bit soul-destroyingbecause now we run our searches
in multiple search engines.
We put the search terms in andthen you specify limits.
(16:56):
So for the IDSI search thatwe're doing right now, we're
trying to be reallycomprehensive and we cast the
net across three or four searchengines and we came up over a 10
year timeframe with 66,000articles.
Speaker 1 (17:15):
It's quite a few to filter through green.
Speaker 2 (17:29):
Yeah, it's crazy.
And of those 66,000, about2,200 look like they might be in
the ballpark.
So we had to eliminate 64,000odd articles, which is kind of
tedious work to do.
Oh, absolutely, and certainlynot fun for graduate students
who are starting this, so youcan understand why people put
(17:50):
limits on, like saying, okay,this is too big.
We're only going to look forarticles that are randomized
control trials.
Speaker 1 (17:56):
Yeah.
Speaker 2 (17:58):
Or we're only going to look at articles, or we're
only going to look at articles,and so that 66,000 was for
articles from 2012 forwardrather than from the dawn of
publication, and so you'll seechoices being made.
There's two systematic reviewsthat I found interesting to
compare a few years ago thatwere both around the efficacy of
(18:19):
behavioral interventions fordysphagia.
That were both around theefficacy of behavioral
interventions for dysphagia andone of them had put like a
five-year limit and the otherhad put an 18-month limit.
And so interesting to stop andsay do I think an 18-month limit
(18:42):
is enough to answer my question?
Is there likely to be enoughmaterial published in the last
18 months?
I would say no, but justinteresting?
Speaker 1 (18:51):
I wouldn't think so.
I mean as much as I feel westruggle to find good studies in
the literature that actuallysubstantiate how effective an
exercise is for a specificpathophysiology or whatever
other outcome for swallowing youhad to limit it to a year and a
half.
I mean like if you limit it to20 years you might get some
(19:12):
stuff, but and I know that, Iknow that recency is is
important, but at the same timethat just does seem really over
over.
Speaker 2 (19:20):
Yeah, that seems overly restrictive to me.
Other limits, you'll see, is,you know, only in English.
Or a very common one that Ithink is worth really thinking
carefully about is do you onlylook for peer reviewed
publications or do you also digbeyond that into what we call
(19:40):
the gray literature?
So the gray literature isthings that actually haven't
made it to publication.
So it might include conferenceabstracts, for example, or
trials that you know areunderway but not yet published.
And it's a bit of a slipperyslope, because then you have to
ask why hasn't it made it topublication?
Is that just timing, or isthere a reason why it hasn it
(20:01):
made it to publication?
Is that just timing, or isthere a reason why it hasn't
made it into publication?
So, personally, I tend to stickto peer-reviewed publications
only.
Sure, but those are choicesthat authors make to manage the
job of the search.
To manage the job of the search, then you should look at how
(20:24):
many people were rating and howwere.
Was this done just by oneperson, for example, and or was
it done by more than one person?
And was there a process forcomparing decisions and
resolving any discrepancies?
Because, like it or not, we'reall prone to bias, and so
deciding whether to include ornot include an article sometimes
(20:48):
can pull on those biases.
So it's really important, Ithink, to have a second reader
and to have them have anopportunity to challenge the
decisions of one person.
Speaker 1 (21:02):
Okay.
Especially when you're workingthrough a huge number, you get
tired too Earlier in the day youmight be a little more
stringent than you are later.
It's like oh, it looks good.
I can see that there would be alot of different things that
would influence that process.
So it sounds like, from whatyou're saying, you've got this
(21:25):
idea and coming into asystematic review.
Speaker 2 (21:26):
how broadly you're going to cast your net.
Speaker 1 (21:29):
So like how, yeah, are you just going to do a title
search?
You can do an abstract,abstract search too.
Are you going to look in onejournal or all of these
different journals or searchareas, and then?
So you have that, and then youhave the filtering process.
So within the filtering process, some things that are important
are make sure they're peerreviewed, I mean, that's at
least.
That is not perfect, but it ofcourse establishes, hopefully
(21:52):
some integrity of the particularone you're looking at.
But then also having a checksand balances system for
inter-rater reliability betweentwo judges to minimize bias, is
that?
Speaker 2 (22:03):
my thought following so far.
Yeah, and then one othercomment to make is often people
will update systematic reviewsat a given frequency and I think
it's important to stop and sayhow likely is it there's new
information in the timeframesince the last review was done,
(22:24):
and here your filters come intoquestion as well.
So there's an example I like touse here is there's a series of
systematic reviews and bestpractice guidelines that fall
out of those that were done by agroup in Denmark looking at the
effectiveness of thickenedliquids for managing, you know,
(22:47):
pneumonia and other downstreamconsequences, and they made a
decision to only look atrandomized, controlled trials.
So the set is pretty small.
And in their first iterationthey found the big study, the
Logum and Robbins Protocol 201studies that were published in
(23:09):
2008.
And that was really one biggrant with a couple of
publications.
And we probably all know thestory that in direct comparison,
within the video fluoroscopythere was less aspiration on the
thicker consistencies, but withuse over time there wasn't a
clear answer and, if anything,randomization of people who are
(23:33):
aspirating to thickened liquidsturned out to be unadvisable
because there were some nastydownstream outcomes
irreplaceable because there weresome nasty downstream outcomes.
So that was their first paperand they concluded it wasn't
strong evidence.
And then three or four yearslater they said let's do this
again.
And I guess the first thing Iwould say is I don't think there
(23:56):
are secret randomized controltrials of big questions hiding
in the literature to find wewould all know if there was a
big study happening.
We could look at something likeclinicaltrialsgov to see if it
was happening.
But they don't appear to havedone that.
So they did the whole exerciseover again and they found the
(24:19):
same two studies and then theyfound one more which was a tiny
study in like 12 or 20 peoplewith a particular etiology that
wasn't strong enough to shiftthe needle at all on the finding
.
And so they published that againand then three or four years
(24:41):
later they cast the net againand exactly the same thing
happened.
They found the Logerman andRobbins papers and one or two
more tiny papers and so evidenceon that question hasn't been
moving because nobody is doing abig study that's randomized and
(25:02):
properly controlled and theexercise of going hunting for it
is a bit futile.
So I think you need to have agood question and to warrant the
effort that goes into it.
I think, make sure nobody elseis already doing it and make
sure that you have something topull, because I've also seen
people presenting reallybeautiful systematic reviews on
(25:27):
a lovely, clear, focusedquestion and they cast their net
and they do all their screeningand at the end of the day they
get zero studies that arerelevant to synthesize and
that's just a waste ofeverybody's time.
It's entirely predictable thata systematic review conclusion
(25:48):
statement will say there'sinsufficient evidence to answer
this question, but to findnothing is a waste of time.
Speaker 1 (26:00):
Yeah, yeah, it's almost.
I mean, we have a lot of valuefor systematic reviews
supposedly being at the top ofthis, this pyramid we look at as
far as levels of evidence go,and I'm trying to think of an
analogy, an analogy to compareit to, because if I mean, if you
don't have the pieces that arenecessary in order to get a good
systematic review, then maybeyou should be working on
(26:20):
designing a good randomizedcontrol trial for the question
rather than pursuing asystematic review.
It almost is like you know,learning to run before you can
walk.
Speaker 2 (26:28):
Yeah, and I do think in dysphagia we struggle because
we know that there's thisevidence-based framework in
medicine, we know that there'sincredible value on randomized
control trials.
But they are so hard to do andin order to get large numbers
(26:53):
for a randomized control trialyou have to decide that a large
number of people are similar andequally likely to benefit or
not benefit from theintervention you're studying.
And I struggle with that as aclinician because it's in direct
(27:17):
tension with the idea that wewant to do personalized
mechanism-specific therapy fordysphagia.
And so you'll see these bigstudies that say we recruited, I
don't know, 100 people withdysphagia post-stroke.
That is not to me a remotelyhomogeneous population.
Speaker 1 (27:43):
Stroke could be anywhere.
Speaker 2 (27:45):
It could be anywhere, the dysphagia could look
different.
I just really reject the ideathat all of those people are
equally likely to benefit from aprescribed uniform therapy.
X.
Speaker 1 (27:57):
No, I totally.
I mean, if you think of thebrain as the controlled system,
you haven't been very specificat all in describing dysphagia.
It's just you know the etiology, so from a neurological cause,
so maybe so you got that.
But it's kind of like lumpingall the dysarthria together.
You could have a flaccid andyou could have a spastic and
it's like, well, you know, thetreatment's gonna work
(28:19):
differently from from flaccidyeah, so, yeah.
Speaker 2 (28:23):
So one of the consequences of this is when you
actually go to places like thecochran collaboration and see
what they've managed to sayabout evidence in our field,
they don't find much, and whatthey do find isn't about
behavioral interventions whichare customized to the patient.
(28:44):
They're about things likeacupuncture or magnetic,
trans-cranial magneticstimulation.
Actually, I would say I'msurprised, in the review that
we're doing right now, about theproportion of studies that are
in the pile that have to do withsomething like transcranial or
(29:07):
rapid TMS.
There's a lot, and the outcomesmight not be measured in ways
that we would like, but it'sjust interesting that there's
such a large body of literature,because I don't think that
doesn't fit with myunderstanding of the kind of
work we're doing.
Speaker 1 (29:26):
Yeah, you said something a second ago and I'm
going to paraphrase.
I'm going to butcher, but thequestions might not be the ones
that we would like.
I believe you said something tothat effect.
That makes me think of, justoverall, if we're asking the
right questions as far asresearch goes, or if we're
looking at the right parameters.
(29:46):
So, in one of the studies youmentioned, as far as the
influence of thickened liquidson different bolus flow
parameters, penetration,aspiration, et cetera, well, I
mean I hate to throw the termcommon sense out there, but if
somebody because I mean what iscommon sense?
(30:07):
Right, but get away from systemtwo a little bit, or system one
a little bit, but withthickened liquids, okay, right,
I mean it might reduce that.
But is that the right questionto ask?
It might reduce airway invasion.
It probably will.
Probably will Someone'saspirating liquids.
You give them nectar, thickliquids, they're probably less
likely to aspirate, unless maybeit's if it's after the swallow.
That's a different story, buttypically, yeah, but I don't
(30:28):
know if that's the rightquestion.
Why do we care about aspiration?
We care about it because wedon't want anyone to asphyxiate
and they can't ventilate and getair in and out and we don't
want it to affect externalrespiration gas exchange between
the alveoli and the capillariesin some way.
And so there's our you know,our pneumonia or whatever else
we're looking at.
(30:49):
So those, to me, are they'reasking the right questions and
that's so important because youcan substantiate a relationship
and you might get a really goodrelationship and say, yeah,
thicken liquids reduceaspiration.
That's great, but it's like, isthat where our focus should be?
It's a good study, but it movesour focus, I think, away from
the big picture outcomes andpotentially doing something that
(31:11):
has potential to be detrimentalin the right patient
populations.
I don't know, that's a soapboxfor me.
Speaker 2 (31:15):
Yeah, it is a soapbox topic and it's a really
controversial one right now.
I've seen arguments in bothways.
I'm actually more on the sideof understanding the
physiological effect of textureand consistency on swallowing,
(31:39):
and I'm very interested, ofcourse, in the long-term
outcomes of addressingsomebody's dysphagia
appropriately.
But to me there are so manyother things that need to be
controlled.
I don't think that texturemodification in and of itself is
enough to mitigate thedifferent mechanisms that
(32:03):
contribute to respiratoryoutcomes or, for that matter,
nutritional and hydrationaloutcomes.
So I think we need to becareful and there's a lot of
papers that ignore thoseconfounding relationships.
So I've always said that Idon't think it's fair to
(32:23):
evaluate a speech pathologyintervention using an outcome
like pneumonia, because I don'tthink we're that powerful.
But, yeah, I do think that weneed to understand that the pros
and cons of thickening and andit's not, it's not always a
(32:44):
beneficial intervention and anddefinitely it's over prescribed,
and we we need to fight forbetter assessment before we
recommend it.
In my opinion, yeah, that yeah,that makes.
Speaker 1 (32:58):
No, that makes a lot of sense to me.
One question that I guess whatcomes out of that is I.
So it's, it's, it'smulti-variate, right, and even
if you, if you simplify it tothe three pillars which there's,
of course, more to it than thethree pillars, you know immune
system status, laryngeal valveintegrity or presence of
(33:19):
aspiration whatever, and oralhygiene even if you just look at
those three things, it showsthat it's multivariate and that
aspiration is probably the leastimportant one.
So the idea that, like, yeah,we're not really that powerful
to control this with, just withthickening liquids or whatever
it is that would help to reducethe bolus and, wow, help to
(33:42):
reduce the bolus and wow, I'mhaving a moment.
Speaker 2 (33:45):
I like to turn the question on its head and so,
rather than saying, do I thinkthickened liquids are the right
thing for this patient and why?
I think the place where I findmyself most challenged is in
asking am I comfortable notconsidering an intervention to
(34:05):
reduce the opportunity foraspirating?
Am I okay with what people callthe risk element?
Here and for some people youmight arrive at a point in
discussion with the patient andthe family and consideration of
all of those elements, that somedegree of informed risk is
(34:29):
something that people arecomfortable with.
But there are certainly in mypatient's caseload history
people where I could not bringmyself to sort of cavalierly say
, go ahead and aspirate, and soI think it's that dynamic and
there, if I know that a changein diet texture limits that
(34:55):
opportunity for transportingthings into the airway, then I
feel I need to explain that andprobably recommend it, Keeping
in mind that of course, peopleaspirate outside the context of
eating and drinking and I thinkmouth care is a really important
part of this equation as well.
Speaker 1 (35:16):
Yeah, no, absolutely.
I think I don't mean todiscredit the importance of
understanding the relationshipof diet textures on bolus flow
parameters.
I think it's important.
I just I also think there's somany other questions within that
to ask too.
Why do we care about this?
(35:37):
But it's kind of like it'sbuilding, they're building
blocks.
Speaker 2 (35:40):
You're building one thing upon the other, upon the
other, and I think you have toknow the answer to these
questions yeah mentioning beforeyeah, it has to be a thorough,
careful consideration, and Ithink I always, I sure hope that
the people who are listeninghave themselves drunk thickened
(36:02):
liquids.
Speaker 1 (36:03):
Oh yeah.
Speaker 2 (36:04):
And you know, spend a day on texture modification and
thickened liquids and thinkabout the impact that that has.
It's huge, and so we should useit wisely and cautiously.
And the other thing you know ifyou want a soapbox is we should
revisit it regularly.
We should give patients theopportunity to return to more
(36:27):
normal eating and drinking atthe earliest possible
opportunity if we can.
So I joke here about in Canada.
we don't have mobile videofluoroscopy vans or mobile
endoscopy vans, but in my labit's kind of a joke.
But it's not really a joke.
(36:48):
We dream of, you know drivingone of these around and finding
all the people who are stuck outthere on enteral feeding or on
texture-modified diets that theyno longer need, who simply
haven't had an opportunity to bere -evaluated.
Speaker 1 (37:07):
Yeah, yeah, not as assuming that they're going to
stay the same.
Speaker 2 (37:12):
Exactly Giving them the opportunity for change.
Speaker 1 (37:14):
No, that makes a whole lot of sense With this
idea of looking at the integrityof systematic reviews, because
it helps, you know, if we'rethinking of the idea of showing
a relationship between atreatment and an outcome within
a controlled setting to see if,well, maybe it will apply to to
(37:37):
our patients, like, obviously,it's going to be incredibly
important that we have faith inthat A lot.
It does sound like.
There are a lot of areas,though, where there can be, oh,
where they can not go wrong, butwhere they may not be as
trustworthy as we would likethem to be, and I know you've
(37:57):
discussed some of that, and whatI would love to do is, after
this, we can chat, and I want tomake sure I write down some of
these resources to be able topoint people to.
On the other side, I want to, Iwould love to hear what you
think is really promising, orwhat you're you're excited about
, like, how are we moving in ain a good direction?
Cause, in my mind, like there isa lot to be critical of as far
(38:21):
as, like these are things we cando better and these are things
we need to be wary of.
At the same time like I'mtrying to be really mindful of
that because I can go really farthat direction.
So I try to still infuse hopeinto things.
So, like what do you see, howare we moving in like the right
direction in this regard?
I mean, I think just this theawareness that people are
getting is moving in the rightdirection, because then they can
be better filters and asclinicians in applying this.
(38:44):
But maybe from the back end,the research side what are you?
What are you excited?
Speaker 2 (38:47):
Well, I do.
I do think the emergence ofguidelines about how to do this
and tools with which to do it isis moving us in the right
direction.
One of the steps we haven'tdiscussed yet is that once you
get your set of articles thatyou think are relevant and meet
your criteria, there's a reallyimportant step in terms of
(39:10):
evaluating the quality of thosearticles.
And at the beginning of thepandemic, I was part of a
journal club that formed reallyjust to stay connected.
So there were six labs, somyself and Sonia Malfenter, who
you mentioned, and AshwiniNamasivam McDonald, who both of
those are my previous doctoralstudents.
(39:34):
And then we pulled in some ofour collaborators, so Rebecca
Afu at Dalhousie University herein Canada and Nicole
Rogaspuglia at Madison Wisconsinand Emily Plowman, and so we
had this journal club and wethought we would get all our
students together and haveregular meetings, and we found
(39:56):
ourselves inevitably, I think,reviewing systematic reviews in
Swallowing, and very quickly thetrainees started to say, yeah,
but there's no common method forevaluating the quality of these
articles from a dysphagiaperspective.
(40:17):
There are tools for evaluatingquality broadly, like the
Cochrane risk of bias tool, andthere are tools that look at
single subject design, but wewere finding that very commonly
and this is still true somebodywould say something like we did
a video fluoroscopy and thenthey wouldn't tell you anything
(40:41):
about how they did that videofluoroscopy things that matter
to the transparency of theirmethods yeah, the rigor and the
transparency just wasn'treported.
So, how many boluses, whattextures were they?
What volumes were they?
Um, what was the barium thatwas used?
(41:02):
What was the frame rate used?
Those kinds of methodologicalconsiderations.
And that video fluoroscopy waslacking.
This Endoscopy was also lacking.
This and so the things that ourtrainees and I should say that
trainees who are doing doctoraldegrees have really sharp
(41:25):
critical teeth, you know,they're trained to go in and
find all the things that arewrong.
And so these methodologicalshortcomings in terms of
reporting, but maybe also interms of how the studies were
actually done, were coming out,and the need for a framework to
critically appraise the qualityof the dysphagia methods came
(41:48):
out of this journal club, and sowe built a critical appraisal
tool and it's public domain.
It's called the FrontiersFramework.
It's httpswwwfrontiersframeworkcom.
I think I'll check that for youand in a beta version it will
(42:10):
be refined over time.
But this group of traineesdesigned the questions that they
felt we needed to be asking andchecking.
So the vision is that it canwork in this exercise of
reviewing the quality of thingsyou're reading, so you can go
check, check, check.
They did or they didn't reportthis, but it's also the vision
(42:36):
is.
It's a tool that you could useif you're designing a study.
You could look at this andthink about all of the things
you need to plan for or, whenyou're writing your own article,
all of the things to check thatyou've included.
And it's quite a humblingexercise to take one of your own
historical articles and run itthrough this critical appraisal
(42:58):
tool and realize all the thingsyou could have reported better
the tool and realize all thethings you could have reported
better.
Speaker 1 (43:07):
Well, I mean, what I like about it is it seems to
have stemmed from a need thatwas made very clear during, like
when you're trying to discussthese articles, that it was kind
of in the forefront of yourmind.
We have these general tools tolook at systematic reviews, but
nothing to evaluate from theperspective of dysphagia.
Speaker 2 (43:23):
So I don't know, and what we found was I think we
looked at three systematicreviews early in the pandemic in
that first few weeks and wefound that all three of these
sets of authors had come up withtheir own tools to address this
short, but they were limited toa particular focus, so we
wanted something a bit broader.
Yeah, so I'm quite excitedabout it.
(43:47):
We will have a series ofarticles coming out in a special
forum in AJSLP later this yearintroducing the tool and the
different themes in the tool,because there are different
sections and when you there'salso a web-based interface.
(44:09):
So when you go into it it askssome basic questions and then it
limits the set.
So if you've only done videofluoroscopy, it'll bring up that
section, but it won't bring upanother section.
That's not relevant.
So what we're hoping is thatpeople will start using it and
give us feedback on it and overtime that will evolve.
(44:31):
I think in a couple of years wethink it'll be time to pull a
consensus panel together to lookat feedback and refine the tool
, but then that it will becomesomething that's a resource
that's useful.
So I've had some fun using itin some workshops with
clinicians just to explore someselected articles, and it's
(44:57):
fascinating.
Actually, the most recent timeI did this, we were looking at
thick and liquids as a topic andso we pulled in Protocol 201
articles as two of the articlesto appraise and so not to say
that the methods weren't donewell, but there are gaps in the
(45:28):
reporting of how those videofluoroscopies were done.
That I think would surprisepeople today and that if we were
doing it again, we would wantto report better.
Speaker 1 (45:38):
Yeah, there are a couple of things that I believe
are really beneficial that havecome from this.
So one you've provided you alltogether have collaborated and
provided this method to evaluateso that we have a better idea
that we're not comparing applesto oranges.
We have a better idea thatwe're we're really measuring
what we think we're measuring.
Speaker 2 (45:58):
Yeah.
Speaker 1 (45:58):
So that's going to help, but also, I think that
this has potential to help inthe production of research too,
because you had mentioned thatother individuals are making
their own, so they're taking allthis time and all this energy
to make their own.
So, but if you have this, thenthat's one less thing they have
to worry about.
They can really focus on theirstudy in other ways and make it
perhaps a little easier to getthings done, which that's
(46:18):
fantastic too.
Speaker 2 (46:19):
Yeah, we hope so.
One of the questions thereviewers asked us is are you
reinventing the wheel Right?
So that people may know?
There's something called theequator network, which is a
place where guidelines live, andso, in order to address the
(46:40):
reviewers' concerns, we also dida scoping review of all of the
guidelines that are housed atthe Equator Network to find out
which of them, if any of them,addressed issues of quality and
rigor and transparency relevantfor dysphagia research.
Want to guess how many we found?
Speaker 1 (47:07):
want to guess how many we found, uh oh, and do the
ones that were just used?
Speaker 2 (47:09):
in those articles count, if not?
I'm going to say zero, zero,zero, zero essentially, we found
that all of these guidelinesare worthwhile, um, but they're
not specific enough to the kindsof things that matter to us as
dysphagia clinicians, and so youneed both, really.
And, yeah, so that that articlewill be coming out as part of
this series, and and that mightbe useful for people too,
(47:33):
because what we did was wemapped the five I think it was
542 guidelines that are werewarehoused at the equator
network as of the date that wedid it, that were warehoused at
the Equator Network as of thedate that we did it, and we
profiled them to say which onesaddress topics that might be
interesting to speech, languagepathologists and dysphagia
researchers.
So that's there, too, to pointpeople to things.
(47:57):
So we don't reinvent the wheel.
Speaker 1 (47:59):
Moving forward, Sure Well, that sounds great, it
sounds very practical.
It complements something thatis already there, but it
provides a deeper level ofspecificity for a very specific
topic.
Speaker 2 (48:12):
Yeah, yeah, I hope so .
Speaker 1 (48:14):
Yeah.
Speaker 2 (48:15):
And I just I want to say again that a huge amount of
the work that's been done aroundthe Frontiers framework and
that Equator Network review wasdone by trainees, and so they
get the authorships and deservethe credit.
Speaker 1 (48:33):
That's excellent.
That is great.
Well, there is always so muchto talk about.
I appreciate everything thatyou've brought up and you
mentioned a number of resourcesthat I want to double check to
make sure I write for thedescription, because I mean,
this is I.
We were, before we startedrecording, talking about some of
the different purposes of thepodcast, and it's one, you know,
(48:56):
to get conversation going, toget people talking about things
that are important, and anotherone is to reduce some of the
power distance between, orperceived power distance, maybe
between clinicians and and thosewho are doing research and
tenure track positions or aretenured at their university,
because sometimes it can beintimidating.
But what I get from this is Imean, everyone has just been so
(49:20):
open to conversation andwelcoming.
I mean you're so people arepassionate about what they do
and they just seem to welcomediscussion.
So I think this kind ofshowcases that.
There was a third thing, ohyeah, the resources too.
Right, so we're not going toget everything on here, but it's
a starting point forconversation If people want to
continue the conversation.
They can check out theseresources or, you know, reach
(49:42):
out any number of things, butit's a beginning.
Speaker 2 (49:45):
Yeah, and if I could plant a bit of an ad here.
I think, you know, once upon atime I was a clinician who was
thinking about research and Iprobably did that.
You know.
Should I do a PhD question fouror five times before the stars
aligned for me?
Speaker 1 (50:04):
I do it about once a week.
Speaker 2 (50:07):
But I had a habit at the time, and I don't know how
open people would be to thishabit, but whenever I went
somewhere, to a professionaldevelopment meeting, I would see
if the local dysphagia guruwould have me for a visit.
And, as the story goes, susanLangmore was one of those people
(50:28):
and she very graciously had mecome and spend a day at her
clinic, and in the course ofthat conversation she said you
should go to dysphagia researchsociety meeting, which I had
never done.
And so I decided sure thatsounds like fun, I'll go.
And so I went along as aclinician and it changed my life
(50:52):
.
I immediately was hooked, andthe opportunity to speak to
established researchers in afairly intimate conference is
extraordinary and to networkwith other people in the field,
and so I'd really love toencourage people to come next
(51:14):
year.
We're going to be inPhiladelphia March 25th to 28th.
I think the networking thathappens at those meetings is
extraordinary and profound.
And so come, we'd love to haveyou, and it is a place where you
can go up to the big names andsay hi and hopefully we'll be
(51:37):
welcoming and interested to meetpeople.
Speaker 1 (51:41):
Yeah, no, I echo that 100%.
Actually, this was the yearwhen it was in San Francisco and
it was DRS and the WorldDysphagia Summit.
Due to some differentparameters, I just attended the
World Dysphagia Summit part ofit and it was very sad to miss
DRS, and this year I was verysad to miss it.
But there is the networking andthe conversation.
(52:05):
Those things are so importantbecause it helps to calibrate us
.
So we're talking about theright things.
That exposes us to differentperspectives and different
questions that we didn't evenknow were out there.
And just within the idea oflearning, okay, you can listen
to a lecture, you can read atextbook, but you really get
into it when you start applyingit in conversation and you get
(52:26):
excited about it and you want tolearn about it.
So you remember it.
There's so much of those thingsthat go on behind the scenes
and I think things like DRS arefantastic in that regard because
it helps to infuse passionwithin everybody and really get
the conversation going.
So, yeah, thank you for.
Speaker 2 (52:44):
And you can also see the battles being fought.
You know, but the debates likeand and think about how people
are pushing the envelope and andexpanding what we know, and I
love that.
I mean you can watch peoplelike me getting up and asking
(53:05):
challenging questions and seehow that goes.
So I think it's really aspecial thing.
It's totally different thangoing to a more clinically
focused meeting, but it doeshave clinical implications and
relevance.
So, yeah, hopefully some ofyour audience will think about
(53:27):
coming.
Speaker 1 (53:28):
Well, I'm hoping to be there.
So, yeah, if you all do end upcoming and are influenced or
were influenced by this episode,come and tap our shoulders, let
us know.
That'd be really cool.
But anyway, thank you so muchfor everything.
Is there anything else thatyou'd like to leave people with
before we wrap up?
Speaker 2 (53:48):
just like to encourage people to keep asking
questions, and the thing I thinkI love most about this field is
the opportunity to keeplearning for sure and
challenging what we know for thebenefit Ultimately, we hope of
our patients.
Speaker 1 (54:08):
Yeah, yeah, I still feel like we're kind of in the
pioneer stage of of.
Speaker 2 (54:11):
We are.
It's an early stage of ourfield.
Speaker 1 (54:15):
So yeah, it's exciting to to at the
opportunity to have an influenceon that.
It's super cool, so yeahabsolutely.
Asking questions.
All right, well, thank you somuch, dr Katrina Steele.
We will include some of theresources that were mentioned
today within the description forthis podcast episode.
That can be found atswallowthegapcom slash podcast
(54:36):
or any of the descriptions onApple podcasts and whatnot.
But thank you so much forjoining and we hope to see you
at VRS.
I hope to be there.
Speaker 2 (54:44):
My pleasure.
Speaker 1 (54:53):
Have a great week.
That brings to close anotherepisode of Swallow the Gap.
A huge thanks to Dr KatrinaSteele for joining us today.
Please see the episodedescription for some resources
that are pertinent to today'scontent, and also see the
episode description for moreinformation from Tim's Medical,
who graciously sponsored thisepisode and will be featuring
Aspect C and upcoming releasesof Tim's MVP in 2025, following
(55:15):
close collaboration with theSwallowing Rehabilitation
Research Laboratory.
For updates on Tim's MVPreleases, follow Tim's Medical
on social media or sign up foremail notifications at
wwwtimscom.
That's T-I-M-S dot com.
I just recorded a fun episodewith Dr Janina Vilmskota from
the Medical University of SouthCarolina.
(55:35):
That's very neuro-focused andit'll be coming out soon, so
keep an eye open for that.
There are several events comingup in the new year.
Hope to see you around for someof those and, either way, thank
you so much for being.
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